1. McNeil, Aundrea MSN

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Discharge planning is a universal priority for all acute care facilities that provide inpatient services. The process of discharge planning includes interdisciplinary care coordination, a framework to guide communication and decision making, and a method to continuously evaluate discharge needs throughout the patient's admission.1,2 The Centers for Medicare and Medicaid Services (CMS) provides discharge planning guidelines and requirements for hospitals (based on the Social Security Act, Section 1861) as a framework to structure their discharge planning process.3 Institutions noncompliant with these guidelines and requirements don't receive reimbursement of care from the CMS.

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At the National Institutes of Health Clinical Center in Bethesda, Md., CMS guidelines and requirements provide a standard for discharge planning. The discharge planning process varies by unit depending on the patient population, research protocol, and/or nursing care model. Nurses are often the first healthcare providers to assess the patient on admission by observation, interviewing, and physical examination. This initial interaction with the patient at the time of admission creates an opportunity for early discharge planning. Nursing staff members are able to identify the patient's discharge needs, make decisions to refer the patient for discharge services, and have a positive impact on patient outcomes.1,2,4


The discharge planning practices on one of our medical-surgical units were inconsistent, which led to miscommunication between disciplines, as well as between healthcare providers and patients. The clinical research nurses (CRNs) on the unit verbalized to nursing leadership their dissatisfaction with the discharge planning process and their desire for involvement within that process. These findings are consistent with discharge process trends seen in other hospitals around the country.1,2,5


Process improvement

To assess the current processes and recommend improvements, the CRNs completed a short questionnaire after discharging a patient. Twenty-five questionnaires were completed within 2 weeks (86% of the total number of patients discharged). Although the actual patient discharge appeared to reflect a smooth transition, the comments of the CRNs revealed a consistent lack of communication between disciplines and the patient. These issues provided critical insight for understanding key drivers and linkages associated with missed opportunities, and avoidable delays in patient discharge. The CRNs were attuned to key areas of opportunity and only somewhat satisfied with the discharge process.


After reviewing the literature on current strategies to improve discharge planning, we developed an evidence-based quality improvement project to structure the discharge planning process.1,2,6 Two focused discussion meetings, which included the unit nursing leadership team and the interdisciplinary discharge planning team, were held to collaborate on strategies to improve discharge planning practices. Current evidence-based practice strategies to improve discharge planning were reviewed, as well as predetermined questions to facilitate the discussions.


The nursing leadership team meeting included the nurse manager, clinical nurse specialist, nurse educator, clinical manager, and three clinical nurses. The interdisciplinary discharge planning team meeting included representation from social work, rehabilitation services, nurse case management, pastoral care, and the research team NP. Participants in both focused discussions identified areas of improvement for discharge planning, including increased nursing staff involvement in the discharge process, interdisciplinary role clarification, guidelines for discharge planning meetings, and a central location to document the discharge care plan.


A structured discharge planning process was developed and six strategies were implemented to structure the process: education for role clarification, guidelines for interdisciplinary discharge planning meetings, CRN and primary CRN (PCRN) attendance at discharge planning meetings, questions to guide discharge planning meeting discussions, a discharge care plan report sheet, and discharge care plan electronic documentation. (See Strategies for structuring the discharge planning process.)


Nursing leadership identified the need to increase PCRN participation in the discharge process. The CRN and PCRN provide nursing care that parallels clinical research requirements. The PCRN collaborates with the research team to develop the care plan.7

Table Strategies for... - Click to enlarge in new windowTable Strategies for structuring the discharge planning process

Piloting success

We piloted the structured process on the medical-surgical unit for 3 months. The CRNs were provided with education on the new process during staff meetings and at interdisciplinary discharge planning meetings. Nursing leadership collaborated with interdisciplinary team members to establish guidelines for discharge planning meetings. Implementation challenges included ensuring CRN availability to attend discharge planning meetings (due to elevated patient census) and increasing the number of CRNs who volunteer to be PCRNs. Every patient didn't have a PCRN.


Three evaluation tools were utilized. The postsurvey was distributed to the CRNs to obtain their perceptions of the process after implementation of the new strategies, utilizing the same questions as the presurvey. The nursing questionnaire to obtain real-time data on patient discharges was also redistributed to the CRNs. There was an increase in CRN involvement and satisfaction with the discharge planning process, which contributed to a sense of increased autonomy in the CRNs' nursing practice. Additionally, a four-question survey was distributed to the interdisciplinary discharge planning team to obtain their perceptions of the structured process. The perception of interdisciplinary communication increased among the CRNs and interdisciplinary team members.


The strategies used to structure the discharge planning process have become standard practice on the unit. In addition, there has been an increase in the number of CRNs volunteering to be PCRNs.


Framework for collaboration

Use of electronic documentation, interdisciplinary meetings, education, and guidelines structured the discharge planning process and provided resources for sustaining the new process. Increasing CRN and PCRN involvement in the discharge process led to early facilitation of discharge planning and a more cohesive experience for our patients. Structuring the discharge planning process provides a framework for all healthcare providers to collaborate on the patient's discharge care plan.




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